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SUNRISE PHARMACY LLC
STD333052 Independent Medical Group, LLC
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Covered Entity Details
Entity Name
Independent Medical Group, LLC
Subdivision Name
Fort Lauderdale
Type
Sexually Transmitted Diseases
340B ID
STD333052
Entity Address
3800 Inverrary Blve
109
Fort Lauderdale, FL 33319
Grant Number
NH25PS004342-04-01
Participating Start Date
9/17/2019
Last Recertification Date
5/9/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
SUNRISE PHARMACY LLC
Pharmacy Address
DBA LAUDERDALE PHARMACY
4000 N STATE ROAD 7 STE 103
LAUDERDALE LAKES, FL 33319-4816
Pharmacy Comments
Contract Details
Approval Date
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/29/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steve Vixamar, COO
(954) 529-1178
Contract Pharmacy Representative
Lauderdale Pharmacy
OLUWOLE A OLUMIDE, PharmD, R.Ph
(954) 530-7171
Signed By Date
1/14/2020
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